Rare EIF4A2 variants are associated with a neurodevelopmental disorder characterized by intellectual disability, hypotonia, and epilepsy.

Eukaryotic initiation factor-4A2 (EIF4A2) is an ATP-dependent RNA helicase and a member of the DEAD-box protein family that recognizes the 5' cap structure of mRNAs, allows mRNA to bind to the ribosome, and plays an important role in microRNA-regulated gene repression. Here, we report on 15 individuals from 14 families presenting with global developmental delay, intellectual disability, hypotonia, epilepsy, and structural brain anomalies, all of whom have extremely rare de novo mono-allelic or inherited bi-allelic variants in EIF4A2. Neurodegeneration was predominantly reported in individuals with bi-allelic variants. Molecular modeling predicts these variants would perturb structural interactions in key protein domains. To determine the pathogenicity of the EIF4A2 variants in vivo, we examined the mono-allelic variants in Drosophila melanogaster (fruit fly) and identified variant-specific behavioral and developmental defects. The fruit fly homolog of EIF4A2 is eIF4A, a negative regulator of decapentaplegic (dpp) signaling that regulates embryo patterning, eye and wing morphogenesis, and stem cell identity determination. Our loss-of-function (LOF) rescue assay demonstrated a pupal lethality phenotype induced by loss of eIF4A, which was fully rescued with human EIF4A2 wild-type (WT) cDNA expression. In comparison, the EIF4A2 variant cDNAs failed or incompletely rescued the lethality. Overall, our findings reveal that EIF4A2 variants cause a genetic neurodevelopmental syndrome with both LOF and gain of function as underlying mechanisms.

Isolated bulbar palsy and dysphagia in children with respiratory symptoms.

Oropharyngeal dysphagia can cause chronic aspiration leading to significant respiratory symptoms. When dysphagia is diagnosed, an underlying cause is sought. We present a case series of 15 children diagnosed aged 6 months to 5 years (mean 2y 5mo; 11 males, four females) over a 6-year period, who were found to have an isolated bulbar palsy on genioglossus electromyography, with no accompanying neurological or neurodevelopmental disorder. Eight children had dysphagia but a normal EMG. In those with isolated bulbar palsy, management included thickened fluids (n=13), cooled boiled water (n=1), and nasogastric tube feeding (n=1). Follow-up over 1 to 8 years (mean 5y) showed complete resolution in six children, improvement in four children, and no improvement in five children (including two requiring fluids via a gastrostomy). Eight children no longer had any respiratory symptoms. Isolated bulbar palsy is under-recognized and has not been reported previously as a cause of significant dysphagia in children.

PIGG variant pathogenicity assessment reveals characteristic features within 19 families.

PURPOSE: Phosphatidylinositol Glycan Anchor Biosynthesis, class G (PIGG) is an ethanolamine phosphate transferase catalyzing the modification of glycosylphosphatidylinositol (GPI). GPI serves as an anchor on the cell membrane for surface proteins called GPI-anchored proteins (GPI-APs). Pathogenic variants in genes involved in the biosynthesis of GPI cause inherited GPI deficiency (IGD), which still needs to be further characterized. METHODS: We describe 22 individuals from 19 unrelated families with biallelic variants in PIGG. We analyzed GPI-AP surface levels on granulocytes and fibroblasts for three and two individuals, respectively. We demonstrated enzymatic activity defects for PIGG variants in vitro in a PIGG/PIGO double knockout system. RESULTS: Phenotypic analysis of reported individuals reveals shared PIGG deficiency-associated features. All tested GPI-APs were unchanged on granulocytes whereas CD73 level in fibroblasts was decreased. In addition to classic IGD symptoms such as hypotonia, intellectual disability/developmental delay (ID/DD), and seizures, individuals with PIGG variants of null or severely decreased activity showed cerebellar atrophy, various neurological manifestations, and mitochondrial dysfunction, a feature increasingly recognized in IGDs. Individuals with mildly decreased activity showed autism spectrum disorder. CONCLUSION: This in vitro system is a useful method to validate the pathogenicity of variants in PIGG and to study PIGG physiological functions.

SCN2A mutation in an infant with Ohtahara syndrome and neuroimaging findings: expanding the phenotype of neuronal migration disorders.

Neuronal migration disorders (NMDs) are a heterogeneous group of conditions caused by the abnormal migration of neuroblasts in the developing brain and nervous system, resulting in severe developmental impairment, intractable epilepsy and intellectual disability (Spalice et al. 2009). To date, many genes have been identified as the leading cause of migration defects, i.e. agyria/pachygyria, polymicrogyria, heterotopias, agenesis of the corpus callosum and agenesis of the cranial nerves (Spalice et al. 2009). Here, we present a patient with early infantile epileptic encephalopathy (Ohtahara syndrome) with seizure onset on the first dayof life, severe developmental delay and an abnormal brain MRI with excessive folding of small, fused gyri and bilateral perisylvian polymicrogyria, suggestive of neuronal migration disorder. To clarify the unknown aetiology, we conducted whole-exome sequencing, which detected a de novo missense variant (c.5308A>T; p.(Met1770Leu)) in the SCN2A gene. This is a report of SCN2A gene variant identified in a patient with neuronal migration disorder which could further expand the phenotypic spectrum of these genetic disorders.

Reversible Cerebral White Matter Abnormalities in Homocystinuria.

Striking MRI brain changes resembling leukoencephalopathy are rarely seen in classical homocystinuria. Our case suggests that reversible white matter changes (WMC) are linked to elevated plasma methionine levels arising during treatment.A 6-year-old boy with learning difficulties and a normal MRI brain scan was diagnosed with homocystinuria (initial total homocysteine 344 µmol/L and methionine 64 µmol/L). At the age of 6.5 years, he developed superior sagittal sinus (SSS) thrombosis. Antithrombotic and homocysteine-lowering treatments were started. Due to poor dietary compliance and betaine treatment, his methionine level reached 1,285 µmol/L, and left side weakness developed. Repeat MRI scan revealed new confluent WMC in previously myelinated brain areas. Further 3-month treatment with tighter dietary control significantly dropped his methionine level (233 µmol/L) with resolution of his neurological deficit and of radiological changes.We suggest a reversible toxicity from hypermethioninaemia as a possible source of cerebral WMC (secondary to a demyelinating process) in patients with homocystinuria. It highlights the importance of homocysteine-lowering treatment as a prevention and complete resolution of neurological complications. It also demonstrates the need to consider homocystinuria in a differential diagnosis of paediatric leukoencephalopathy.

GLUT-1 deficiency presenting with seizures and reversible leukoencephalopathy on MRI imaging.

Glucose transporter type 1 (GLUT1) deficiency syndrome is a well recognised genetic neurometabolic disorder typically presenting with progressive encephalopathy, acquired microcephaly and drug-resistant epilepsy. Imaging is normal in the majority. Here we describe a 5-month-old boy who presented with motor delay, myoclonic jerks and tonic-clonic seizures. His MRI brain scan revealed confluent symmetrical T2 hyperintense signal abnormality in both anterior frontal lobes and delayed myelination. Neurometabolic screen revealed low CSF glucose and lactate levels. A pathogenic de novo heterozygous mutation in SLC2A1 (c.275+1G > A) confirmed the diagnosis of GLUT1 deficiency. Ketogenic diet resulted in a dramatic termination of his seizures at 72 h. At 15 months, he continued to be seizure free with marked developmental catch up. Repeat imaging revealed a significant resolution of the previously seen changes. This case suggests that GLUT1 deficiency should be considered in the differential diagnosis of infants with suspected genetic leukoencephalopathies with important treatment implications.

Ketogenic diet therapy in infants less than two years of age for medically refractory epilepsy.

PURPOSE: The Ketogenic Diet (KD) is a well-established treatment for epilepsy in children and adults. We describe our 10-year KD experience in children less than two years of age diagnosed with medically refractory epilepsy. METHODS: We conducted a retrospective case-note review of infants managed with KD at our centre between 2006 and 2016. RESULTS: Twenty-nine children between 2½ weeks and 23 months of age were identified, with mixed epilepsy aetiologies. Ninety-three percent had daily seizures and 82% were on two or more anti-epilepsy drugs (AEDs) at the time of KD commencement. KD was continued for more than four weeks in 86%. Based on a combination of parental reports, hospital observations and seizure diaries, two of 29 became seizure free, seven demonstrated >50% seizure reduction, and eight showed a decrease in seizure intensity/frequency. No adverse effects were observed in 45% patients, and dietary therapy was stopped in only two because of poor tolerability. CONCLUSION: We conclude that KD can be utilised and is generally well tolerated in infants with severe epilepsies. In addition, our experience suggests efficacy with improved seizure frequency/severity in around 50% without adverse effects on developmental outcome.

Use of the Ketogenic Diet to Treat Intractable Epilepsy in Mitochondrial Disorders.

Mitochondrial disorders are a clinically heterogeneous group of disorders that are caused by defects in the respiratory chain, the metabolic pathway of the adenosine tri-phosphate (ATP) production system. Epilepsy is a common and important feature of these disorders and its management can be challenging. Epileptic seizures in the context of mitochondrial disease are usually treated with conventional anti-epileptic medication, apart from valproic acid. However, in accordance with the treatment of intractable epilepsy where there are limited treatment options, the ketogenic diet (KD) has been considered as an alternative therapy. The use of the KD and its more palatable formulations has shown promising results. It is especially indicated and effective in the treatment of mitochondrial disorders due to complex I deficiency. Further research into the mechanism of action and the neuroprotective properties of the KD will allow more targeted therapeutic strategies and thus optimize the treatment of both epilepsy in the context of mitochondrial disorders but also in other neurodegenerative disorders.

Alteration of intravenous nicotine self-administration by opioid receptor agonist and antagonists in rats.

RATIONALE: The role played by endogenous opioids in mediating the reinforcing properties of nicotine is unclear. As with preclinical studies, clinical trials with naloxone, a prototypic opioid receptor antagonist have yielded equivocal findings with regard to its efficacy in reducing cigarette smoking. OBJECTIVE: The aim of the present study was to examine the effects of three opioids that exhibit relative selectivity at mu-, kappa- and delta-opioid receptors on nicotine self-administration in male hooded Lister rats. METHODS: Graded doses (0.3, 1.0, and 3.0 mg/kg IP) of each opioid agonist or antagonist were tested in different groups of rats repeatedly over three consecutive nicotine intravenous nicotine-self administration (0.03 mg/kg/infusion) sessions. The same treatments were tested in parallel groups of rats trained to respond for food reinforcement. RESULTS: Naloxone was very effective in attenuating the levels of nicotine self-administered across all doses tested. The selective kappa-opioid receptor agonist U50,488, reduced nicotine self-administration in doses of 1 and 3 mg/kg, while the 0.3 mg/kg dose produced a small increase in nicotine intake. Finally, the specific delta-opioid receptor antagonist, naltrindole did not significantly modify nicotine self-administration behaviour. In contrast, all three opioids failed to modify behaviour maintained by food reinforcement. CONCLUSIONS: These findings suggest endogenous opioids are crucial in mediating the reinforcing effects of nicotine and that the mu-opioid receptor subtype may represent a potential target for selectively reducing nicotine-taking behaviour as part of a pharmacological approach to develop smoking cessation aids.

Changes in mGlu5 receptor expression in the basal ganglia of reserpinised rats.

Dopamine depletion in Parkinson's disease results in a series of pathophysiological changes in the basal ganglia circuitry. Increased release of glutamate plays an important role in this motor disorder, therefore, agents interacting with glutamatergic transmission may have therapeutic potential. In this study we investigated changes in both mRNA expression and the number of binding sites of the mGlu5 receptor in a reserpinised rat model of Parkinson's disease. The in situ hybridisation demonstrated that acute reserpine treatment caused a significant decrease in the expression of mGlu5 receptor mRNA in the rostral and caudal parts of the rat striatum. At the same time, tritium-labelled 2-ethyl-6-(phenylethynyl)-pyridine ([(3)H]MPEP) ligand binding experiments detected a significant increase in the total number of mGlu5 receptors in the same region of the motor loop. These apparently contradictory data can be explained by mGlu5 receptor turnover being down-regulated in reserpinised rats, due possibly to an imbalance in the rates of synthesis/insertion and internalisation/degradation of the receptor. These findings suggest that changes such as these affecting mGlu5 receptors may be involved in the pathophysiological consequences of dopamine depletion in the brain.

Effects of adenosine A1, dopamine D1 and metabotropic glutamate 5 receptors-modulating agents on locomotion of the reserpinised rats.

The pathophysiology of Parkinson's disease and l-3,4-dihydroxyphenylalanine (l-DOPA)-induced dyskinesia are characterised by an imbalance between activity of the direct and indirect pathways regulated by dopamine D1 and D2 receptors, respectively. In this study, we investigated the effects of treatments combining adenosine A(1) and metabotropic glutamate 5 (mGlu5) receptors modulators on locomotion induced by dopamine D1 receptor activation in the reserpine-treated rats. Administration of the adenosine A(1) receptor agonist and mGlu5 receptor antagonist resulted in the significant reduction of dopamine D1 receptor agonist-induced locomotion. The combination of adenosine A(1) receptor agonist with mGlu5 receptor antagonist had no greater effect than these compounds alone. However, the adenosine A(1) receptor antagonist attenuated the inhibitory effect of mGlu5 receptor antagonist. The data suggest that the effect of mGlu5 receptor blockade on locomotion elicited by dopamine D1 receptor stimulation involves activation of adenosine A(1) receptors. This interaction can improve our understanding of pathophysiology of L-DOPA-induced dyskinesia.